2018 MEDIHELP RATES - 54 PRACTICE Kindly see below Tariffs for Medihelp. Please note that not all tariff codes listed are covered by the respective
|
|
|
- Donna Page
- 5 years ago
- Views:
Transcription
1 2018 MEDIHELP RATES - 54 PRACTICE Kindly see below Tariffs for Medihelp. Please note that not all tariff codes listed are covered by the respective TARIFF CODE DESCRIPTION 2018 RATES 8101 Oral examination Limited oral examination Intraoral radiograph - periapical Infection control/barrier techniques Sterilized instrumentation Intraoral radiograph - bitewing Extraoral radiograph - panoramic Pulp removal (pulpectomy) Recement inlay, onlay, crown or veneer Remove inlay, onlay or crown House/extended care facility/hospital call Inhalation sedation - first 15 minutes or part thereof Inhalation sedation - each addnl 15 minutes Intravenous sedation Local anaesthetic - per visit Polishing - complete dentition Prophylaxis - complete dentition Topical application of fluoride - child Dental sealant Occlusal guard Prophylaxis - complete dentition (periodontally compromised patient) Extraction - tooth or exposed tooth roots (first per quadrant) Extraction - each additional tooth or exposed tooth roots Surgical removal of residual roots, first tooth per quadrant Surgical removal of residual roots, second and subsequent teeth's roots Cost of suture material Complete dentures - maxillary and mandibular Complete denture - maxillary or mandibular Partial denture - resin base - one tooth Partial denture - resin base - two teeth Partial denture - resin base - three teeth Partial denture - resin base - four teeth Partial denture - resin base - five teeth Partial denture - resin base - six teeth Partial denture - resin base - seven teeth Partial denture - resin base - eight teeth Partial denture - resin base - nine or more teeth Immediate denture - maxillary Immediate denture - mandibular Clasp or rest - stainless steel Bar - lingual or palatal Rebase complete or partial denture (laboratory) Remodel complete or partial denture Reline complete or partial denture (chair-side) Tissues conditioning per arch (including soft self- cure reline) Reline complete or partial denture (laboratory) Repair denture or other intra-oral appliance
2 8271 Add tooth to existing partial denture Impression to repair or modify a denture or other intra-oral appliance Partial denture - cast metal framework only Pulp amputation (pulpotomy) Root canal obturation - anteriors and premolars - each additional canal Root canal therapy - anteriors and premolars - each additional canal Removal of root canal obstruction Root canal preparatory visit - single canal tooth Root canal preparatory visit - multi canal tooth Re-treatment of previously completed root canal therapy, per canal Root canal obturation - anteriors and premolars - first canal Root canal obturation - posteriors - first canal Root canal obturation - posteriors - each additional canal Root canal therapy - anteriors and premolars - first canal Root canal therapy - posteriors - first canal Root canal therapy - posteriors - each additional canal Amalgam - one surface Amalgam - two surfaces Amalgam - three surfaces Amalgam - four or more surfaces Resin - one surface, anterior Resin - two surfaces, anterior Resin - three surfaces, anterior Resin - four or more surfaces, anterior Prefabricated metal crown Resin - one surface, posterior Resin - two surfaces, posterior Resin - three surfaces, posterior Resin - four or more surfaces, posterior Core build-up with prefabricated posts Cost of prefabricated posts Cast core with single post Cast post (each additional) Core build-up with pins Crown - full cast metal Crown - 3/4 cast metal Crown - 3/4 porcelain/ceramic Crown - resin laboratory Crown - resin with metal Crown - porcelain/ceramic Crown - porcelain veneered to metal Repair crown (permanent or provisional) Pontic - ceramic Pontic - cast metal Pontic - resin with metal Pontic - porcelain veneered to metal Provisional pontic Crown retainer - full cast metal Crown retainer - ceramic
3 8444 Crown retainer - 3/4 ceramic Crown retainer - porcelain veneered to metal Crown retainer - resin with metal Provisional crown retainer Recement bridge Remove bridge Implant supported removable complete overdenture Implant supported removable partial overdenture Crown-implant/abutment supported crown - porcelain/ceramic Crown-implant/abutment supported crown - porcelain with metal Crown-implant/abutment supported crown - cast metal Implant supported crown retainer - ceramic Implant supported crown retainer - porcelain veneered to metal Crown retainer - implant/abutment supported - cast metal Cost of ceramic block Fabrication of computer generated ceramic restoration Crown - implant/abutment supported Cost of implant components Covered 8654 Implant supported fixed-detachable complete overdenture Implant supported fixed-detachable partial overdenture Additional fee to implant supported fixed- detachable denture - per implant Incision & drainage of abscess - intra-oral Root planing - four or more teeth per quadrant Root planing - one to three teeth per quadrant Occlusal orthotic appliance Biopsy of oral tissue - soft Surgical removal of impacted tooth - first tooth Surgical removal of impacted tooth - second tooth Surgical removal of impacted tooth - third and subsequent teeth Surgical removal of residual roots, first tooth - per tooth Frenulectomy/frenulotomy Incision & drainage of abscess - intra-oral (pyogenic) Apicectomy/periradicular surgery - anteriors (including retrograde filling) Apicectomy/periradicular surgery - molars (including retrograde filling) Surgical placement of sub-periosteal implant - placement stage Surgical placement of endosteal implant plate Surgical placement of endosseus implant - first per quadrant Surgical placement of endosseus implant - second per quadrant Surgical placement of endosseus implant - third and subsequent per quadrant Cost of endosteal implant body Covered 9188 Cost of prefabricated abutment Covered 9189 Cost of other implant componets Covered 9190 Surgical exposure of endosseus implant - first per quadrant Surgical exposure of endosseus implant - second per quadrant Surgical exposure of endosseus implant - third and subsequent per quadrant Lab codes 9301 Casting and trimming of model in plaster (yellow/white), per model Casting and trimming of model in super-hard stone (die-stone) per model Casting and trimming of study model, per model 96.70
4 9307 Casting and trimming of gnathostatic model, per model New trimmed base to supplied model, per model Refractory model, per unit Occlusion block on baseplate, per block Infection control per impression, denture (wax or acrylic) or any item in contact 9327 with body fluids Fit and supply of disposable articulator Full upper and lower dentures Full upper or lower denture Set-up and waxing of full upper and lower dentures Set-up and waxing of full upper or lower denture Waxing and finishing of full upper and lower dentures Waxing and finishing of full upper or lower denture Additional fee for dentures on fully adjustable articulator at request of dentist Additional fee for immediate dentures, or tooth socketed Additional fee for immediate dentures, per tooth not socketed Additional fee for each retry from the third and upwards at an agreed quantum of 9347 time to be calculated at hourly rate Set-up and finish of one-tooth denture Set-up and finish of two-tooth denture Set-up and finish of three-tooth denture Set-up and finish of four-tooth denture Set-up and finish of five-tooth denture Set-up and finish of six-tooth denture Set-up and finish of seven-tooth denture Set-up and finish of eight-tooth denture Set-up and finish nine or more tooth denture Set-up and waxing of one-tooth denture Set-up and waxing of two-tooth denture Set-up and waxing of three-tooth denture Set-up and waxing of four-tooth denture Set-up and waxing of five-tooth denture Set-up and waxing of six-tooth denture Set-up and waxing of seven-tooth denture Set-up and waxing of eight-tooth denture Set-up and waxing of nine or more tooth denture Waxing and finishing of one-tooth denture Waxing and finishing of two-tooth denture Waxing and finishing of three-tooth denture Waxing and finishing of four-tooth denture Waxing and finishing of five-tooth denture Waxing and finishing of six-tooth denture Waxing and finishing of seven-tooth denture Waxing and finishing of eighth-tooth denture Waxing and finishing of nine or more tooth denture Additional fee for finishing denture in tooth colour material, per tooth Additional fee for supplying finished denture on duplicate model Basic charge which includes repair of one fracture, or addition of one tooth, or 9391 addition of one clasp
5 9393 Additional charge for each additional fracture, or tooth, or clasp Additional fee for using wire strengthener Additional fee for using pre-formed strengthener Additional fee for using mesh strengthener in repair procedure Clear base Covered 9403 Dox grinding of upper and lower dentures Inlay to artificial tooth, one surface only, per inlay Covered 9406 Inlay to artificial tooth, multi-surfaces e.g. horseshoe or l-type inlay, per inlay Covered 9407 Heka base technique per upper or lower denture Frego frame Template per upper or lower denture Reline/rebase of single denture Remodel of single denture Soft base reline per denture Soft base to new denture, per denture Gum tinting per denture Covered 9423 Lingual or palatal bar Mesh strengthener Special tray, acrylic, each Special tray light cure, each Special tray in base plate material, each Provision of single arm clasp, to partial denture Provision of double arm clasp, to partial denture Provision of single arm clasp with rest, to partial denture Provision of double arm clasp with rest, to partial denture Provision of preformed roach clasp, to partial denture Provision of rest only to partial denture Cast clasp Casting and trimming of model from impression inside occlusion block or wax try in Basic charge - which excludes models and any special trays which may be required 9453 by the dentist, but includes refractory model Additional charge for each one arm clasp Additional charge for each roach clasp Additional charge for each rest Additional charge for continuous clasp, per tooth Additional charge for lingual bar, per tooth passed Additional charge for palatal bar Additional charge for saddle with finishing line, per tooth Additional charge for saddle without finishing line, per tooth Additional charge for horseshoe saddle, per tooth Additional charge for fitting of tooth to metal backing, per tooth Additional charge for fitting one distal-extension hinge Additional charge per milled edge per tooth Additional charge for each soldering joint Additional charge for soldering retention Additional charge for each additional retention soldering joint Additional charge for each welding joint Additional charge for fitting swing lock
6 9491 Additional charge for each backing cast Additional charge for each steels backing or pontic cast (plastic work to be charged 9493 in addition) Basic fee for the repairing of or addition to any appliance necessitating the casting 9495 of a model (9301) Basic fee if a new section is to be fabricated and where item 9495 does not apply 9497 (9301) Post-solder invested joint, per joint Porcelain shoulder per unit (not applicable to pontics) Full metal crown, mod, three-quarter crown Additional fee for one piece casting of crown or inlay on post Abutment thimble cast Gold/pre-solder invested joint Covered 9546 Multiple post Manufacture cast post and core to existing crown Composite/acrylic veneer crown/pontic, indirect Indirect composite resin veneer Covered 9563 Temporary acrylic/composite crown per unit Covered Additional fee for each remake at an agreed quantum of time to be calculated at an 9570 hourly rate Covered 9571 Basic charge which includes acrylic base Basic charge non acrylic base Additional fee for full aclusal bite plate Additional fee for fitting tongue guard Additional fee for ball clasp Invisible retainer Covered 9621 Additional fee for fitting extra-oral arch Additional fee for fitting space maintainer arch Mouth protector (gum guard) Covered 9635 Andresen or norwegian appliance Frankel appliance Chin cap Bionator Diagnostic set-up Covered 9651 Pinched or swaged band with welded attachment (excluding cost of attachment) Diatorics, odds, posterior Soft base material per denture Acrylic per denture Cost of precision attachment, per attachment Covered 9726 Preformed ball or roach clasp Cost of implant components Covered 9767 Soldering material R/A case Covered 9776 Cost of mouth protector material Covered 9778 Cost of Arch Wire Dual laminate material Covered Positioning and finishing of complete (male and female)pre fabricated burn-out 9780 attachment Covered 9782 Positioning and soldering of complete (male and femal) precision attachement Covered
7 9784 Alignment of dolder bar and clips Covered Trimming, waxing and finishing of implant abutment - crown and bridge work only, 9786 per abutment Waxing, milling and finishing of a custom abutment
RETIREE DENTAL PLAN. RETIREE DENTAL PLAN FEE SCHEDULE Page 1 of 8
D0120 periodic oral evaluation $ 30.50 D0140 limited oral evaluation problem focused $ 30.50 D0150 comprehensive oral evaluation - new or established patient $ 30.50 D0160 detailed and extensive oral evaluation
Employee Benefit Fund July 2018 ADA Codes and Plan Fees
CSEA Employee Benefit Fund July 2018 ADA Codes and Plan Fees DIAGNOSTIC D0120 periodic oral examination 40 34 42 45 48 38 30 32 31 D0140 limited oral examination (Does not look at 9110) 40 34 42 45 48
DIAGNOSTIC/PREVENTIVE SERVICES
DIAGNOSTIC/PREVENTIVE SERVICES Diagnostic Services D0120 Periodic oral evaluation 100% 100% D0140 Limited oral evaluation problem focused 100% 100% D0150 Comprehensive oral evaluation 100% 100% D0160 Detailed
Delta Dental of Colorado EXCLUSIVE PANEL OPTION (EPO) Schedule EPO 1B List of Patient Co-Payments. * See Special Provisions on Last Page
List of Co-Payments Code edure Code Definition Co-Pay DIAGNOSTIC CODES D0120 Periodic oral evaluation - established patient $10.00 D0140 Limited oral evaluation - problem focused $10.00 D0145 Oral evaluation
2018 fee schedule. Georgia. Diagnostic Services (Performed by a General Dentist)
Diagnostic Services (Performed by a General Dentist) page 1 of 12 IS NOT A REGISTERED INSURANCE PLAN. It is a savings plan offered exclusively by Coast Dental practices to patients who do not have dental
Managed DentalGuard Texas
Page 1 of 5 0120 0120 0140 0140 0150 0150 0460 0470 0999 9310 9310 9430 9440 0210 0220 0230 0240 0270 0272 0274 0330 1110 1120 1999 1201 1203 1204 1310 1330 1351 9999 1510 1515 1550 2110 2120 2130 2131
D0120 Periodic Oral Examination $31 D0140 Limited Oral Evaluation Problem Focused $41 D0145 Oral Evaluation Patient Under 3 $28 D0150 Comprehensive
D0120 Periodic Oral Examination $31 D0140 Limited Oral Evaluation Problem Focused $41 D0145 Oral Evaluation Patient Under 3 $28 D0150 Comprehensive Oral Examination $43 D0160 Detailed And Extensive Oral
General Dentist Fee Schedule
General Dentist Fee Schedule ADA Diagnostic D0120 Periodic oral evaluation $0 $72 $72 D0140 Limited oral evaluation problem focused $77 $107 $30 D0150 Comprehensive oral evaluation new or established patient
General Dentist Fee Schedule
General Dentist Fee Schedule Diagnostic D0120 Periodic oral evaluation $0 $59 $59 D0140 Limited oral evaluation problem focused $71 $88 $17 D0150 Comprehensive oral evaluation new or established patient
Scheduled Dental Benefit Plan Schedule of Dental Allowances
Diagnostic Scheduled Dental Benefit Plan Schedule of Dental Allowances 0120 Periodic Oral Evaluation (once in 5 months after comprehensive) 20.00 0140 Limited Oral Evaluation 20.00 0150 Comprehensive Oral
Schedule of Benefits (GR-9N S )
Schedule of Benefits (GR-9N S-01-001-01) Employer: Group Policy Number: BNSF Railway Company GP-727796 Issue Date: January 1, 2016 Effective Date: January 1, 2016 Schedule: 1A Cert Base: 1 For: DMO - All
Delta Dental of Colorado DENVER HEALTH AND HOSPITAL AUTHORITY GROUP #587. EXCLUSIVE PANEL OPTION (EPO) List of Patient Copayments
List of Copayments Code edure Code Definition Copay DIAGNOSTIC CODES D0120 Periodic oral evaluation - established patient $10.00 D0140 Limited oral evaluation - problem focused $10.00 D0145 Oral evaluation
GUARANTY ASSURANCE COMPANY Dina Dental of Louisiana Pre-Paid Group & Individual
Effective: January 1, 2016 Eligibility: (866) 436-3093 GUARANTY ASSURANCE COMPANY Dina Dental of Louisiana Pre-Paid Group & Individual Diagnostic D0999 Office Visit Copay - Per Person, Per Visit $9.00
Schedule of Benefits (GR-9N S )
Schedule of Benefits (GR-9N S-01-001-01) Employer: Group Policy Number: Roman Catholic Diocese Of Dallas GP-870560-WI Issue Date: February 9, 2015 Effective Date: January 1, 2015 Schedule: 7A Cert Base:
GUARANTY ASSURANCE COMPANY - DINA Dental Plan SCHEDULED BENEFITS RIDER
OSHA Charge for disposables for patients protection, per person, per visit* $5.00 120 Periodic oral exam $5.00 140 Limited oral exam $30.00 150 Comprehensive oral evaluation $20.00 180 Comprehensive Perio
Exclusive Panel Option (EPO 1-B) a feature of the Delta Dental PPO Denver Public Schools- Group #
Exclusive Panel Option (EPO 1-B) a feature of the Delta Dental PPO Denver Public Schools- Group #6694 7.2011 MAXIMUM BENEFIT Calendar Year Orthodontic Lifetime CALENDAR YEAR DEDUCTIBLE WHO CAN BE COVERED
Delta Dental EPO City & County of Denver Group #6791 EPO
MAXIMUM BENEFIT - Calendar Year Maximum Delta Dental EPO City & County of Denver Group #6791 EPO Unlimited See copayment schedule for additional details. Orthodontic Lifetime Unlimited See copayment schedule
SECURE CHOICE INDIVIDUAL COPAYMENT SCHEDULE
DentiCare of Alabama, Inc. 3595 Grandview Parkway, Suite 650 Birmingham, AL 35243 SECURE CHOICE INDIVIDUAL COPAYMENT SCHEDULE SECTION I: PLAN DENTIST SERVICES (Subject to Exclusions and Limitations Listed
LIST OF COVERED DENTAL SERVICES
LIST OF COVERED DENTAL SERVICES The following is a complete list of those dental Services which will be considered for payment by Constitution Life Insurance Company after the expiration of any applicable
SECTION 8 DENTAL BENEFITS SCHEDULE OF DENTAL BENEFITS
SECTION 8 DENTAL BENEFITS The Fund pays up to a maximum of $2,000 per year for Dental expenses incurred by Participants and/or Dependents age 19 or over in accordance with the Schedule of Dental benefits;
Schedule of Benefits (GR-9N S )
Schedule of Benefits (GR-9N S-01-001-01) Employer: Group Policy Number: BNSF Railway Company GP-727796 Issue Date: January 1, 2014 Effective Date: January 1, 2014 Schedule: 1A Cert Base: 1 For: DMO - All
Senior Dental Insurance Scheduled Allowance
Senior Dental Insurance Scheduled Allowance LIST OF COVERED DENTAL SERVICES The following is a complete list of those dental services which will be considered for payment by The American Progressive Life
Aetna Dental Inc. One Prudential Circle Sugar Land, TX SUMMARY OF COVERAGE
Aetna Dental Inc. One Prudential Circle Sugar Land, TX 77478 1-877-238-6200 SUMMARY OF COVERAGE CONTRACT HOLDER: BNSF Railway Company GROUP AGREEMENT: 727796 PLAN EFFECTIVE: January 1, 2016 The benefits
MDG Dental Plan Comparison
D0999 Office visit during regular hours, general dentist only Evaluations D0120 Periodic oral examination - established patient D0140 Limited oral evaluation - problem focused D0145 Oral evaluation for
MY SMILE DENTAL PLAN FEE SCHEDULE
D0120 periodic oral evaluation D0140 limited oral evaluation problem focused D0145 exam under 3 years D0150 comprehensive oral evaluation - new or established patient D0160 detailed and extensive oral
Fee Schedule Detail Procedure Procedure Description Code Fee
Fee Schedule Detail Procedure Procedure Description Code Fee D0120 PERIODIC ORAL EVALUATION - ESTABLISHED PATIENT $ 32.29 D0140 LIMITED ORAL EVALUATION-PROBLEM FOCUSED $ 53.02 D0150 COMPREHENSIVE ORAL
Delta Dental PPO EPO PLAN DESIGN THE NORFOLK CONSORTIUM
Delta Dental PPO EPO PLAN DESIGN THE NORFOLK CONSORTIUM SCHEDULE OF BENEFITS AND COPAYMENTS/ The benefits shown below are performed as deemed appropriate by the attending Dentist subject to the limitations
Delta Dental EPO City & County of Denver Group #6791 EPO
MAXIMUM BENEFIT - Calendar Year Maximum Delta Dental EPO City & County of Denver Group #6791 EPO Unlimited See copayment schedule for additional details. Orthodontic Lifetime Unlimited See copayment schedule
For a Correction Captains Association Dental Claim Form please follow this link CCA Dental Claim form.pdf
Correction Captains Association Retiree Security Benefit Fund Group #132 Summary of Benefit for Retired members: Annual maximum $3,500.00 individual Individual Ortho Lifetime max $3,500 Appliance $600,
Aetna Dental Inc. One Prudential Circle Sugar Land, TX SUMMARY OF COVERAGE
Aetna Dental Inc. One Prudential Circle Sugar Land, TX 77478 1-877-238-6200 SUMMARY OF COVERAGE CONTRACT HOLDER: Clear Creek ISD GROUP AGREEMENT: 620318 PLAN EFFECTIVE: September 1, 2014 The benefits shown
This schedule applies to services provided by a participating General Dentist and is an extensive list of most common procedures. The purpose of this schedule is to establish the maximum fee that a General
This schedule applies to services provided by a participating General Dentist and is an extensive list of most common procedures. The purpose of this schedule is to establish the maximum fee that a General
EXHIBIT A PROCEDURE DESCRIPTION MSP50809 CDT CODE
D0120 Periodic Exam 28.00 D0140 Limited Oral Evaluation Problem Focused 42.00 D0145 Oral Evaluation for a Patient Under Three Years of Age and Counseling with Primary Caregiver 38.00 D0150 Comprehensive
ASSISTANT SECRETARY PRESIDENT
Charge Code TYPE I* Benefit Co-Insurance $21.00 0120* Periodic oral exam $21.00 Balance Billing $30.00 0140* Limited oral exam $30.00 Balance Billing $35.00 0150* Comprehensive oral evaluation $35.00 Balance
DELTA DENTAL PPO EPO PLAN DESIGN CP070
DELTA DENTAL PPO EPO PLAN DESIGN CP070 SCHEDULE OF BENEFITS AND The benefits shown below are performed as deemed appropriate by the attending Dentist subject to the limitations and exclusions of the program.
FEE SCHEDULE. Complete Dental Plan is a discount plan offered and administered by our organization at:
FEE SCHEDULE Complete Dental Plan is a discount plan offered and administered by our organization at: 7801 CORAL WAY SUITE # 106, MIAMI, FL 33144 (786) 326-6873 F (305) 6979785 COMPLETE DENTAL PLAN HIGHLIGHTS
Newport News Public Schools Summary Schedule of Services Delta Dental PPO EPO Plan
Newport News Public Schools Summary of Services Delta Dental PPO EPO Plan Services In-Network Out-of-Network PPO Premier All Other Diagnostic & Preventive Oral Exams & Teeth Cleanings Fluoride Applications
Concordia Plus Schedule of Benefits
Concordia Plus Schedule of Benefits Plan MD/DC 6 IMPORTANT INFORMATION ABOUT YOUR PLAN This schedule of benefits provides a listing of procedures covered by your plan. For procedures that require a copayment,
IRON WORKERS BENEFIT TRUST SCHEDULE OF DENTAL SERVICES AND SUPPLIES D0100-D0999 I. Diagnostic Clinical Oral Evaluations periodic oral evaluation
D0120 IRON WORKERS BENEFIT TRUST SCHEDULE OF DENTAL SERVICES AND SUPPLIES D0100-D0999 I. Diagnostic Clinical Oral Evaluations periodic oral evaluation established patient* $ 66.50 D0140 limited oral evaluation
DINA Dental. Prepaid Plan Highlights. Prepaid Plan Bi-weekly Premiums $ 7.00 $10.76 $ Employee Only Employee + One Employee + Family
DINA Dental Prepaid Plan Highlights NO Claim Forms NO Maximums NO Deductibles NO Waiting Period - Some Preventive and Diagnostic Services Provided at NO CHARGE - Over 180 procedures covered by co-payments
APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE
: EPSDT DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program. All procedures
DENTAL GRID - SCMEBF Page 1 of 8 Vol. 1 #7 as of 1/16/18
0120 Periodic oral evaluation - established patient $25 0140 Limited oral evaluation - problem focused $30 0150 Comprehensive oral eval.-new or established patient $35 0160 0180 Detailed & extensive oral
LOUISIANA MEDICAID PROGRAM ISSUED: 08/18/14 REPLACED: 09/15/13 CHAPTER 16: DENTAL SERVICES APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE PAGE(S) 16
APPENDIX A: FEE SCHEDULE DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program.
Summary of Benefits - Dental HMO Deluxe Plan
Office visit Office visit $5 per visit Diagnostic (exams and x-rays) D0120 Periodic oral evaluation You pay nothing D0140 Limited oral evaluation - problem focused You pay nothing D0145 Oral evaluation
Improve your smile and overall well-being with. Dental Health Services. Dental Health Services. Difference today!
Improve your smile and overall well-being with Dental Health Services Great oral health is essential for your overall well-being. With a Dental Health Services plan, you can achieve a healthy smile while
LOUISIANA MEDICAID PROGRAM ISSUED: 09/15/13 REPLACED: 03/28/13 CHAPTER 16: DENTAL SERVICES APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE PAGE(S) 16
APPENDIX A: FEE SCHEDULE DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program.
Recommended Professional Fee
Fee Guide Development & Negotiation Committee 2018 Recommended Professional Fee and Laboratory Fee Guide Abbreviations T: Time Units / 1 Unit = 15 Minutes G: Gold L: Lab Disbursement E: Extra Expense B.R.:
APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE
: EPSDT DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program. All procedures
Please note a few important reminders to help expedite the process of dental claims/estimates:
To: Valued Members and Providers From: Member Services Date: January 2019 RE: Attached is the for all members. Note: The Plan Pays amount on the fee schedule already has the percentages factored in. The
APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE
: EPSDT DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program. All procedures
Teachers' Dental Plan Maximum Reimbursement Levels
Teachers' Superannuation Commission Dentist Payment Schedule Teachers' Dental Plan Maximum Reimbursement Levels January 1, 2019 Teachers' Teachers' Dental Dental Description Code Plan Description Code
AmeriPlan Lime Fee Zip: 78411
AmeriPlan Lime Fee Zip: 78411 SPECIALIST FEE SCHEDULE Any AmeriPlan /Dental Plans of America member receiving treatment from a participating specialist provider (advanced degree), shall receive a 15% discount
Concordia Plus Schedule of Benefits
Concordia Plus Schedule of Benefits Plan TX IMPORTANT INFORMATION ABOUT YOUR PLAN The pays a $ office visit Copayment per visit in addition to the Copayments listed on this Schedule of Benefits. This schedule
Covered Dental Services and Patient Charges U10TXI04
The services covered by this Plan are named in this list. If a service, treatment or procedure is not on this list, it is not a covered service. All services must be provided by the assigned PCD. The Member
Where a restoration is provided, no payment will be made for stainless steel crown or prefabricated plastic crown for thirty (30) days.
CHILD DENTAL BENEFITS Effective July 1, 2017 to June 30, 2019 Child dental coverage is provided to dependant children of Alberta Adult Health Benefit (AAHB) and Income Support receipients (Expected to
Careington Corporation Care PPO Schedule CI-10
Careington Corporation Care PPO Schedule Page 1 of 5 This schedule applies to services provided by a participating General Dentist and is an extensive list of most common procedures. The purpose of this
cigna dental care (*DHMO) patient charge schedule
C15V9 Subject to regulatory approval cigna dental care (*DHMO) patient charge schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights
EssentialSmile Ped 221 Schedule of Benefits
EssentialSmile Ped 221 Schedule of Benefits P.O. Box 19199 Plantation, FL 33318 Telephone: 877-760-2247 Fax: 954-370-1701 www.mysolstice.net Members can search for a Network Provider at www.solsticecare.com/provider-search.aspx
Diagnostic No One of (D0210, D0330) per 36 Month(s) Per patient No No Ten of (D0230) per 1 Day(s) Per patient.
Dental and Authorization Guide Diagnostic services include the oral examinations, and selected radiographs, needed to assess the oral health, diagnose oral pathology, and develop an adequate treatment
The. Dental Plan. Underwritten by: DENTA-CHEK of Maryland, Inc. A Not-for-Profit Corporation
The Dental Plan Underwritten by: DENTA-CHEK of Maryland, Inc. A Not-for-Profit Corporation Now you can have comprehensive DENTAL coverage at a cost you can afford! Since 1981, Denta-Chek has been providing
EssentialSmile Ped 221 Schedule of Benefits
EssentialSmile Ped 221 Schedule of Benefits P.O. Box 9 Plantation, FL 33318 Telephone: 877 760 2247 Fax: 954 370 1701 www.mysolstice.net Members can search for a Network Provider atwww.solsticecare.com/provider
deltadentalins.com/usc
Plan Benefit Highlights for: UNIVERSITY OF SOUTHERN CALIFORNIA STUDENT PLAN Group No: 05008 The Delta Dental PPO table plan provides you great dental benefits at a reasonable cost. With a table of allowance
DELTA DENTAL OF CALIFORNIA Client Name: University of Southern California Student Health Plan Group No.: 05008
DELTA DENTAL OF CALIFORNIA Client Name: University of Southern California Student Health Plan Group No.: 05008 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO TABLE OF ALLOWANCE The Delta Dental PPO table plan
Dentists. Schedule of Dental Services and Fees for Ontario Works Adults
Dentists Schedule of Dental Services and Fees for Ontario Works Adults 2017 2017 Ontario Works Adults - Schedule of Dental Services and Fees PURPOSE OF THE PROGRAM Halton Region does not intend to provide
ADA CODE ADA DESCRIPTION NV FEES PREVENTATIVE D0120 Periodic oral evaluation - established patient 50 D0150 Comprehensive oral evaluation - new or
ADA CODE ADA DESCRIPTION NV FEES PREVENTATIVE D0120 Periodic oral evaluation - established patient 50 D0150 Comprehensive oral evaluation - new or established patient(initial exam) 0 D0160 Detailed and
The following services may be provided:
CHILD HEALTH BENEFIT DENTAL COVERAGE Effective July 1, 2017 to June 30, 2019 Child Health Benefit (CHB) dental coverage is provided to dependant children enrolled in the Alberta Child Health Benefit (ACHB)
LIBERTY Dental Plan of Florida, Inc. FL800NS Copayment Schedule
LIBERTY Dental Plan of Florida, Inc. FL800NS Copayment Schedule Members must select, and be assigned to, a LIBERTY Dental Plan contracted dental office to utilize covered benefits. LIBERTY Dental Plan
SHL Dental PPO Plan 29 - SB Adult Only Coverage
SHL Dental PPO Plan 29 - SB Adult Only Coverage Attachment A Benefit Schedule Please read the definition of Eligible Dental Expenses ( EDE ) and SHL Reimbursement Schedule in the Certificate. When accessing
SECURECARE DENTAL SCHEDULE OF OUT OF NETWORK BENEFIT PAYMENTS GENERAL INFORMATION
SECURECARE DENTAL SCHEDULE OF OUT OF NETWORK S GENERAL INFORMATION This Schedule applies only to services and supplies furnished by Non-Preferred Providers. The patient will be responsible for all charges
PLEASE READ IMPORTANT PLAN INFORMATION AT THE END OF THIS SCHEDULE
Careington Corporation Care POS Schedule CI-4 Please Call 800-290-0523 for Customer Service ***Discount plans are not insurance*** This schedule applies to services provided by a participating General
MDG-FP-U10NYI04-SCH-NY-OFF-17
SECTION XVI MANAGED DENTALGUARD SCHEDULE OF BENEFITS COST-SHARING PEDIATRIC DENTAL CARE ESSENTIAL HEALTH BENEFIT Deductible One (1) Member under Age 19 Two (2) or More Members under Age 19 Participating
This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.
A3O09 cigna dental care (*DHMO) patient charge schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies
Real people, real benefits
Real people, real benefits Thank you for considering a HumanaDental plan. Enroll exclusively at www.ers.state.tx.us Learn more at HumanaDental.com/ers We re committed to providing you with the benefits
SCHEDULE A Description of Benefits and Copayments DHMO-901
866.650.3660 WWW.PREMIERLIFE.COM SCHEDULE A Description of Benefits and Copayments DHMO-901 The benefits shown below are performed as deemed appropriate by the attending Primary Care Dentist subject to
Staywell FL Child Medicaid Plan Benefits
The following is a complete list of dental procedures for which benefits are payable under this Plan. For beneficiaries under age 21, additional coverage may be available with documentation of medical
All Participants and Beneficiaries in the Health and Benefit Trust Fund of the International Union
SUMMARY OF MATERIAL MODIFICATIONS TO THE HEALTH AND BENEFIT TRUST FUND OF THE INTERNATIONAL UNION OF OPERATING ENGINEERS LOCAL UNION NO. 94 94A 94B, AFL CIO To: From: All Participants and Beneficiaries
SECTION XVI. EssentialSmile Ped 111, ST, INN, Pediatric Dental SCHEDULE OF BENEFITS
SECTION XVI. EssentialSmile Ped 111, ST, INN, Pediatric Dental SCHEDULE OF BENEFITS COST-SHARING PEDIATRIC DENTAL CARE ESSENTIAL HEALTH BENEFIT Deductible One (1) Member under age 19 Two (2) or more Members
Summary of Benefits Dental Coverage - New Dental Option
Summary of Benefits Dental Coverage - New Dental Option Managed Dental Plan MET225 - Texas Code Description Co-Payment Diagnostic Treatment D0120 Periodic Oral Evaluation established patient $0 D0150 Comprehensive
2018 Dental Schedule of Allowances Indemnity Dental Plan for Active Plan A, Plan B, and all Retirees
2018 Dental Schedule of Allowances Indemnity Dental Plan for Active Plan A, Plan B, and all Retirees Schedule effective date for all Plans: January 1, 2018 Annual Deductibles For all Plans: $50 per person
Managed DentalGuard - Plan Schedule
D0999 Office visit during regular hours, general dentist only * $5 Evaluations D0120 Periodic oral examination established patient 0 D0140 Limited oral evaluation problem focused 0 D0145 Oral evaluation
Anthem Blue Dental PPO Voluntary Option 2V Summary of Benefits
Anthem Blue Dental PPO Voluntary Option 2V Summary of Benefits Annual Benefit Limit: $1500 Annual Member Deductible: $50 PPO Dentist $50 Non-PPO Dentist Family Coverage Deductible Limit 3 times Annual
LIST OF COVERED DENTAL SERVICES PREVENTIVE SERVICES
The Guardian Life Insurance Company of America A Mutual Company Incorporated 1860 by the State of New York 7 Hanover Square, New York, New York 10004 (212)598-8000 DENTAL POLICY OUTLINE OF COVERAGE This
Massachusetts Family High Dental Plan with Enhanced Child Orthodontia
SCHEDULE OF BENEFITS Massachusetts Family High Dental Plan with Enhanced Child Orthodontia This Schedule of Benefits lists the services available under the MetLife plan, as well as the co-insurance payments
CHOICES Patients Covered dental services
CHOICES Patients Covered dental services Important points: There is a $7 co-pay for each covered service visit at the UF College of Dentistry except for some denture therapy services which may require
BOSTON TEACHERS UNION PARAPROFESSIONAL HEALTH AND WELFARE FUND Schedule of Covered Dental Procedures for the Dental Plan - Effective January 1, 2009
TYPE 1 D0120 Periodic oral evaluation 27.81 D0140 Limited oral evaluation - problem focused 43.15 D0145 Oral evaluation for a patient under three years of age and 22.20 counseling with primary caregiver
DMO Dental Benefits Summary
CODE PROCEDURE Office Visit Copay PATIENT PAYS $0 CODE DIAGNOSTIC PROCEDURE PATIENT PAYS D0120-D0180 Oral Evaluations D0277 Vertical Bitewings - 7 to 8 Films D0210 Full mouth series X-rays D0330 Panoramic
SECURECARE DENTAL COPAY PLAN AZ300 - SCHEDULE OF DENTIST COPAYMENTS
The Copay Plan is a fee-for-service dental plan designed with convenient copays. If the treating dentist is a General Dentist, the patient is responsible for the Genteral Dentist Copay(s) for services
SECURECARE DENTAL COPAY PLAN NV100 - SCHEDULE OF DENTIST COPAYMENTS
The Copay Plan is a fee-for-service dental plan designed with convenient copays. If the treating dentist is a General Dentist, the patient is responsible for the Genteral Dentist Copay(s) for services
23XX2293 R3/08 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company
www.bcbsla.com 23XX2293 R3/08 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company 1 Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc. are
TEAMSTERSCARE DENTAL FEE SCHEDULE Effective: 01/01/ Delta Dental PPO Plus Premier National
Effective: 01/01/ - Delta Dental PPO Plus Premier National D0120 PERIODIC ORAL EXAMINATION $21.00 D0140 LIMITED EVAL PROBLEM FOCUS $38.00 D0145 ORAL EVALUATION FOR PATIENTS UNDER THREE YEARS OF AGE $21.00
NDB Nevada Kids Silver In-Network Schedule of Benefits
NDB Nevada Kids Silver Diagnostic D0120 Periodic Oral Evaluation Established Patient (1 per 6 months)... No Charge D0140 Limited Oral Evaluation Problem Focused (3 per 6 months)... No Charge D0145 Oral
SCHEDULE OF BENEFITS POLICY BENEFITS
The Guardian Life Insurance Company of America A Mutual Company Incorporated 1860 by the State of New York 7 Hanover Square, New York, New York 10004 SCHEDULE OF BENEFITS The Schedule of Benefits provides
SECTION XVI. EssentialSmile Ped 111, ST, INN, Pediatric Dental Schedule of Benefits
COST-SHARING SECTION XVI. EssentialSmile Ped 111, ST, INN, Pediatric Dental Schedule of Benefits Members can search for a Network Provider at www.solsticecare.com/provider-search.aspx Member Services:
CHAPTER 6 Dental Services
CHAPTER 6 Dental Services Propunere noua clasificare proceduri folosind codificarea ICD-10-AM versiunea 3, 30 martie 2004 BLOCK 450 Dental examination 97012-00 Periodic oral examination 97013-00 Limited
LIBERTY Dental Plan of California, Inc. CA-80 Plan Benefit Schedule
LIBERTY Dental Plan of California, Inc. CA-80 Plan Benefit Schedule Summary of Services Provider office preassignment is not required. However, members must visit a LIBERTY Dental Plan contracted dental
Texas Essential Health Benefit PLUS Family Plan with EHB PLUS (for Children)
This summary of benefits, along with the exclusions and limitations describe the benefits of the Essential Health Benefit PLUS Family Plan with EHB PLUS (for Children). Please review closely to understand